First and foremost, we need to understand what you are experiencing…
Anxiety is a feeling that all of us experience. Being able to feel anxiety is very useful to us in all kinds of situations. It is, in fact, essential to our survival. But maybe you are seeking help because you feel you have too much anxiety, some of the time or even most of the time. Or maybe you feel you need help coping with your anxiety because it causes you too much suffering or interferes with your functioning.
The first step in anxiety treatment is to understand, as fully as possible, what you are actually experiencing. Do you feel worried, uneasy or unsettled? Or do you feel disquieted, noisy inside and not quite able to rest your mind? Lastly, you might feel a powerful sense of dread, panic or terror.
We also want to understand when your anxiety arises and how it affects you – both for better and for worse. Does anxiety keep you from falling asleep, awaken you during the night or seize you in the morning? Does it prevent you from focusing during the day? Is it associated with certain obvious triggers, like performance situations or airplane flights, or does it seem to arise out of the blue? (In my experience, what seems out of the blue before beginning treatment usually comes to make some sense—often a lot of sense—as we come to understand it. That is, we come to see links to internal and external factors that you were not initially aware of – but more about that later.)
Some Concerns You May Have About Anxiety Treatment
Some people wish they felt less anxious, but also feel they need to remain anxious in order to be on alert for external dangers, to keep their edge so they can continue to perform at a high level or to hold themselves together and on familiar ground. There is some rational basis for this attitude, since anxiety can mobilize us as well as provide us with essential information about our internal and external worlds. So we owe it to ourselves to pay attention to it and seek to understand what your anxiety might be trying to tell us. But we also need to understand whether you harbor a belief, conscious or not, that any relief of your anxiety will actually cause you to stop functioning or even to fall apart.
So, coming to understand your anxiety may entail addressing any or all of these yearnings and concerns. We must proceed thoughtfully and sensitively, not hastily or in a cookbook fashion, as there is no simple recipe for recovering from anxiety. You will not hear from me, for example, “I practice evidence-based medicine, and the literature shows that the best treatment for anxiety is blah-blah-blah, so that is what you should do.”
Psychotherapy And Anxiety Treatment
Having said that, I would like to tell you a little more about how I typically approach anxiety treatment. First, understanding your anxiety is not just a prelude to your treatment; it is an ongoing aspect, maybe even the centerpiece, of your treatment. The more we are able to find words for what you experience, in an atmosphere of acceptance, patience, and empathy, the more relief you are likely to experience. Whatever genetic factors or other biological underpinnings you may have that contribute to your anxiety, there are likely psychological factors as well. Some of these may not currently be within your conscious awareness, or only dimly so. Oftentimes, you will experience lasting and profound relief of your anxiety as we come to understand how it relates to emotionally meaningful circumstances in both your past and present. One additional form of psychotherapy for anxiety is ketamine-assisted psychotherapy, which I describe on another page entitled Ketamine-Assisted Psychotherapy.
“Anti-anxiety” Medications
In other instances, additional tools may be a useful part of your anxiety treatment. One such tool is “anti-anxiety” medication. Like psychotherapy, psychopharmacology (treatment with psychiatric medication) is a complicated topic, but I will try to provide an overview of some factors to consider. The first issue to consider is the goal of anti-anxiety medication. Realistically, it would not be to eliminate or vanquish all anxiety. After all, as I wrote above, there is a healthy level of anxiety that needs to be considered on an individual basis. But the goal of anti-anxiety medication may be to reduce the intensity of your anxiety in general and/or in specific circumstances. Anti-anxiety medications may be taken every day for people who are highly anxious most or all of the time. In other circumstances, anti-anxiety medications are used only in anticipation of predictable anxiety-provoking situations, such as airplane flights, scheduled performance situations or CT scans. At other times, anti-anxiety medications may be used in response to a sudden increase of anxiety, like at the first onset of a panic attack or during a very stressful social situation that you were not anticipating.
With that framework in mind, SSRIs such as Prozac, or SNRIs such as Effexor, are medications that must be taken every day to be effective during anxiety treatment, so they are only appropriate for people who are highly anxious most or all of the time. Their use requires patience, not only because they typically take several weeks to begin to work, but also because most side effects appear before the benefits. Fortunately, most side effects of these medications are not serious, but they can be unpleasant and interfere with your functioning. If these side effects do occur, they can sometimes be managed with certain strategies or with the passage of time. But we do need to remain vigilant to more serious side effects that infrequently occur, such as a medication-induced mania.
Benzodiazepines, such as Ativan or Klonopin, are also sometimes used every day for people who are highly anxious most or all of the time. Unlike SSRIs and SSRIs, they begin to work very quickly. However, they can cause more dangerous side effects, both short term and long term. Given these risks, we try to use them as briefly as possible or, since they begin to work quickly, on an as-need basis before or during very stressful situations. In any case, it is important to be very careful when using these medications.
Sometimes people experiencing anxiety have accompanying physical symptoms, such as racing heart, tremulousness, flushing or heavy perspiration. When these symptoms occur, people may become more self-conscious and therefore more anxious, resulting in a vicious cycle. This cycle can become especially problematic in social or performance situations when a person is already preoccupied with how they (believe they) are appearing to others. Under those circumstances, one strategy can be to interrupt the cycle by blocking or reducing the physical manifestations of anxiety. That task can sometimes be accomplished with the use of beta-blockers, which are generally well tolerated and safe.
There are other psychiatric medications that may be useful during anxiety treatment, such as Remeron, Buspar, Neurontin and atypical neuroleptics. Each has their pros and cons and can be thoughtfully considered in the context of a consultation or ongoing treatment. It is important to keep in mind that medications are just tools. They are rarely a replacement for a therapeutic relationship geared toward understanding your anxiety in the context of who you are as a person. In my experience, as you come to make sense to yourself and to others, you are likely to feel profound relief of your anxiety.
